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Youth Membership Form
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* Indicates required question
1. Full Name:
*
Your answer
2. Date of Birth:
*
MM
/
DD
/
YYYY
3. Age:
*
Below 18 yrs
18-25 Yrs
25-35 yrs
Other:
4. Gender:
*
Female
Male
Prefer not to say
Other:
5. Address (Street, City, State, ZIP):
*
Your answer
6. Email Address:
*
Your answer
7. Phone Number:
*
Your answer
8. Preferred method of contact (Email / Phone / Text):
*
Your answer
9. Emergency Contact Name:
*
Your answer
10. Emergency person's relationship with you:
*
Your answer
11. Emergency Contact Phone Number:
*
Your answer
12. Current School / Educational Institution (if applicable):
Your answer
13. Grade / Year:
Your answer
14. Are you currently employed?
*
Yes
No
15. If yes, where do you work and what is your job role?
Your answer
16. Do you have any medical conditions or allergies we should be aware of?
*
Your answer
17. Please specify your medical condition or allergies if any.
Your answer
18. Why are you interested in participating in our youth services?
*
Your answer
19. What areas would you like to focus on? (Check all that apply.)
*
Academic support
Career guidance
Leadership development
Mental health & wellness
Community service
Arts & creative expression
Sports & fitness
Other:
Required
20. What personal goals would you like to achieve through this program?
*
Your answer
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